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* micro questions with explan....from step prep... #128620

nishi - 10/15/06 16:12

Step 2 CS Matching & Residency Step 3 hey everyone, i m feeling too sleepy and tired...so i m posting it all at once with explan...sorry about that....hope this helps...

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A 26-year-old obstetric patient becomes acutely ill during her first trimester with infectious mononucleosis-like symptoms, but her heterophil antibody test was negative. A careful history reveals that the family has two cats in the house. The appropriate laboratory tests indicate the expectant mother is infected with Toxoplasma gondii. Months later, the woman delivers a full term baby with no obvious signs of infection with the protozoan parasite. The best test to diagnose acute infection in the neonate would be a parasite-specific ELISA for which isotype of immunoglobulin? A. IgA B. IgE C. IgG 1 D. IgG 4 E. IgM Explanation: The correct answer is E. IgM immunoglobulin directed against Toxoplasma would provide evidence of infection in the newborn baby. IgM is the only antibody that a baby can form with an acute infection. It is the first antibody that is formed in an infection and it is also the antibody that is present on the surface of immature and mature B cells. IgA (choice A) is the antibody that is produced in response to mucosal infections. It cannot cross the placenta. The baby's immune system is still not well developed at birth and cannot produce IgA immunoglobulin. In adults or older children, IgA is exists in serum in a monomeric form but is present in seromucous secretions as a dimer. IgE (choice B) is the antibody that is produced in response to an allergen. It cannot cross the placenta, and is not present in the baby at birth or for some time after birth. The baby's immune system is still not well developed at birth and can initially only form IgM immunoglobulin.

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IgG 1 (choice C) and IgG4 (choice D) immunoglobulins might be present in the baby, but would not indicate infection in the infant. The presence of these isotypes would indicate that the mother was infected with the organism and produced antibody that was transported across the placenta in utero. IgG is the only immunoglobulin that can cross the placenta, providing protection to the baby during the first few months of life. Which of the following organisms is a natural transformer? A. Escherichia coli B. Neisseria gonorrhoeae C. Plasmodium vivax D. Pseudomonas aeruginosa E. Staphylococcus aureus Explanation: The correct answer is B. Transformation is the uptake and integration of naked DNA by a bacteria from the environment. Transformation can be induced in the laboratory (a technique used to introduce gene-carrying plasmids into bacteria) or, relatively uncommonly, occurs naturally. Only a few medically important species undergo natural transformation: Haemophilus species, Streptococcus species, Neisseria gonorrhoeae, and Helicobacter pylori. Which of the following structures is found only in Gram-negative microorganisms? A. Cell envelope B. Exotoxin C. Peptidoglycan D. Periplasmic space E. Teichoic acids Explanation: The correct answer is D. This question requires you to appreciate the key structural difference between gram-positive and gram-negative microorganisms. Most gram-negatives (other than exceptional microorganisms, such as Mycoplasma, that lack a cell wall) have a more complex cell envelope than gram-positive microorganisms. It includes both a cytoplasmic membrane as well as an outer membrane. Between these two membranes is the periplasmic space, which contains enzymes such as phosphatase and penicillinase, binding proteins for the transport of various nutrients, and peptidoglycan, as well as a portion of the lipoprotein that firmly anchors the outer membrane to the peptidoglycan. Gram-positives do not have outer membranes.

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Choice A, the cell envelope, is incorrect because both gram-positive and gram-negative microorganisms have this structure, which is defined as all the layers that enclose the cytosol of the bacterium. It is the composition of the envelope that differs between gram-positives and gram-negatives. Choice B, exotoxin, is not exclusive to gram-negative microorganisms, but is also found in some gram-positives. By contrast, endotoxin (lipopolysaccharide; LPS) is found exclusively in gramnegatives. Choice C, peptidoglycan, is found in the cell walls of both gram-positive and gram-negative microorganisms. Note that there is a larger amount of peptidoglycan in gram-positive microorganisms. Choice E, teichoic acids, are found exclusively in gram-positive organisms. A 23-year-old, ill-appearing woman comes to the emergency room with a fever. She notes the recent development of nausea, diarrhea, and a rash. Her last menstrual period began 3 days ago. Physical examination is remarkable for blood pressure of 90/45 mm Hg and heart rate of 120 beats per minute. A diffuse erythematous rash with areas of desquamation over the hands and feet is noted. Infection with which of the following agents is the most likely cause of these signs and symptoms? A. Clostridium perfringens B. HIV-1 C. Shigella dysenteriae D. Staphylococcus aureus E. Staphylococcus epidermidis Explanation: The correct answer is D. This patient has toxic shock syndrome (TSS), a multisystem syndrome caused by a toxin (TSST-1) formed by certain strains of S. aureus. TSS usually affects several organ systems (gastrointestinal, renal, hepatic, hematopoietic, musculoskeletal, pulmonary) and can result in death. TSS has historically been associated with the use of tampons in young women, but can also occur in other patient populations. Fever, hypotension, diarrhea, and diffuse rash with desquamation of the hands and feet are common symptoms. Management of shock, renal failure, and adult respiratory distress syndrome (ARDS) are a priority if these conditions are present, in addition to appropriate antibacterial treatment. C. perfringens(choice A) causes gas gangrene, with necrosis of soft tissues, usually after a traumatic wound. It is also a cause of food poisoning.

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Although HIV-1 (choice B) can cause many diverse findings and should never be immediately ruled out, the findings in this patient are most specific for TSS. Shigella dysenteriae(choice C) is a cause of dysentery characterized by fever, abdominal cramps, and bloody diarrhea. S. epidermidis(choice E) is part of the normal skin flora, but is notorious for causing infections of intravenous lines and prosthetic heart valves. A pregnant southeast Asian immigrant presents for prenatal care. Her past medical history is significant for a severe illness 3 years ago characterized by fatigue, nausea, anorexia, vomiting, jaundice, joint pains, and generalized skin lesions that slowly disappeared. She has felt well recently. Which of the following laboratory tests should be ordered to investigate the patient's past illness? A. Hepatitis B surface antigen (HBsAg) B. IgG cytomegalovirus (CMV) antibody levels C. IgM antibody to HBsAg D. IgM antibody to hepatitis B core antigen E. Quantitation of hepatitis A virus (HAV) IgM antibody Explanation: The correct answer is A. The clinical signs suggest that this woman had hepatitis B three years ago and the fact that she is now feeling better also suggests that she recovered from this infection. Since she is pregnant, it is necessary to find out if she still has the organism in her liver (chronic hepatitis B infection) by performing a test for HBsAg. This test will be negative if she has completely recovered from the disease, but it would be positive if she is a chronic carrier. The clinical signs of the disease she had 3 years ago do not match those of CMV (choice B), and CMV does not produce chronic infections. Measurement of IgM antibody to hepatitis B core antigen (choice D) would be of no value at this time. This antibody is positive in acute cases of hepatitis B, but would no longer be positive in this case. Measurement of IgM anti-hepatitis B core antigen is one of the most important tests in the hepatitis profile because the appearance of the antibody correlates with the disappearance of HBsAg. Examination of IgM antibody to HBsAg (choice C) would be of no value at this time. This IgM antibody would be formed early during the recovery from acute hepatitis B, and would class switch to IgG later on in the disease. Quantitation of hepatitis A virus (HAV) IgM antibody (choice E) would be useless, since

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hepatitis A virus (HAV) only causes acute infection. The rationale for giving prophylactic antibiotics at the beginning of a surgical procedure can be thought of as an attempt to prevent the bacteria from entering which of the following growth phases? A. Death phase B. Lag phase C. Log phase D. Phase of decline E. Stationary phase Explanation: The correct answer is C. A single dose of a prophylactic antibiotic given as surgery is about to begin (sometimes given intravenously to assure the timing) has become more common because it is associated with a decreased wound infection rate. Such antibiotic usage does not prevent organisms from entering the tissues, but effectively prevents them from becoming established as they try to grow and divide (e.g., leave the lag phase (choice B) and enter the log or exponential phase of colony growth). The stationary phase (choice E) and phase of decline (choice D) (formerly called death phase, choice A) would occur much later, after a colony had been established (which is what the surgeons were trying to prevent). A 10-year-old girl presents with sore throat and fever. She denies any cough or rhinorrhea. A throat culture grows bacitracin-sensitive bacterial colonies. The infecting organism would be protected from the lytic action of detergents by its A. keratin-like proteins in the spore coat B. lipopolysaccharide in the outer membrane C. peptidoglycan layer D. periplasmic space E. Ca2+ chelators Explanation: The correct answer is C. This girl has streptococcal pharyngitis. The infecting organism is group A beta-hemolytic streptococcus (S. pyogenes); its growth is inhibited by the placement of a bacitracin disk on the throat culture plate. (Betahemolysis occurs as the result of the bacterial hemolysin streptolysin S). This is a gram-positive bacterium and therefore possesses a very thick peptidoglycan layer that would protect it from lysis by detergents. (Note that gram-positives also contain teichoic acid.) In contrast, gram-negatives have a thin peptidoglycan layer. Keratin-like proteins in the spore coat (choice A) and

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calcium ion chelators (dipicolinic acid) (choice E) are found in spores formed by species of Bacillus and Clostridium. These protect the spores from the elements: dehydration, heat, chemicals, radiation, etc. Lipopolysaccharide in the outer membrane (choice B) and a periplasmic space (choice D) are found in gram-negative organisms. The lipopolysaccharide is an endotoxin and the periplasmic space contains beta-lactamase in some species. An antibiotic, such as penicillin, which modifies cell wall synthesis, tends to be most effective during which phase of bacterial growth in a closed system? A. Lag phase B. Log phase C. Phase of decline D. Stationary phase Explanation: The correct answer is B. Bacterial growth in a closed system is characterized by four phases: (1) In the initial lag phase, no growth occurs as the organisms adapt to the new environment. (2) In the exponential, or log phase, the organisms grow at the fastest rate and antibiotics that interfere with cell growth or division are most likely to be effective. (3) In the stationary phase, when nutrients have been largely exhausted, organisms tend to stop growing but may remain viable for long periods of time. (4) In the phase of decline, cell deaths increase due to cell starvation or exposure to toxins. A 14-year-old patient is brought in by his parents because of a sore throat. On physical examination, he is febrile, and has pharyngeal erythema with a tonsillar abscess. A throat culture on sheep blood agar yields colonies of gram-positive cocci that are surrounded by a zone of complete hemolysis. The organism was also plated on mannitol salt agar; it grew well and caused the medium to turn yellow. Which of the following microorganisms is the most likely cause of the patient's illness? A. Corynebacterium diphtheriae B. Haemophilus influenzae C. Staphylococcus aureus D. Streptococcus salivarius E. Streptococcus pyogenes Explanation:

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The correct answer is C. The description of the agent is consistent with a staphylococcal organism (catalase-positive, gram-positive cocci that grows on mannitol salt agar. The organism is most likely S. aureus, as it was able to ferment mannitol (as evidenced by the color change in the mannitol salt agar after incubation) and was beta-hemolytic. Other characteristics of this organism are coagulase production and excretion of DNAse from colonies. Staphylococcal organisms are also notorious for formation of abscesses; the patient had an abscess in the tonsillar region. The diphtheria bacilli (Corynebacterium diphtheriae; choice A) are gram-positive, pleomorphic rods that are arranged in palisades. They are non-hemolytic and would not grow on mannitol salt agar. These organisms produce a whitish-gray pseudomembrane on the pharynx or the larynx; constitutional symptoms from toxemia are the major features of diphtheria. Epiglottitis is the most common disease of the upper respiratory tract produced by Haemophilus influenzae(choice B), a gram-negative, encapsulated rod. It is also a common cause of otitis media in children and may cause bronchitis, bronchiolitis, and pneumonia in adults. Streptococcus salivarius(choice D) is a gram-positive coccus that is usually alpha-hemolytic. It is normal flora of the oral cavity and is sometimes implicated in subacute bacterial endocarditis, but is not associated with tonsillar abscesses. Streptococcus pyogenes(choice E) is a beta-hemolytic, gram-positive coccus that grows in chains, as opposed to the random, grape-like clusters of the staphylococci. These organisms are the most common cause of pharyngitis, which is usually manifested by severe sore throat, fever, a beefy red pharynx, and a tonsillar exudate. A 14-year-old boy is brought to the emergency department by his parents because of high fever, headache, and stiff neck for the past 36 hours. He has become confused over the course of the morning. He uses no medications, has no allergies, and is not sexually active. On examination, he has a temperature of 38 C, moderate nuchal rigidity, and marked photophobia. Lumbar puncture is performed, and the cerebrospinal fluid shows: WBC 3500 with 95% PMNs, elevated protein, decreased glucose, and gram-positive cocci in pairs and short chains. By which of the following mechanisms does this organism mediate its attachment to the respiratory mucosa? A. Production of a C carbohydrate B. Production of a hemolytic exotoxin C. Production of a hyaluronic acid capsule D. Production of an IgA protease E. Production of an M protein

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Explanation: The correct answer is D. This is a case of Streptococcus pneumoniae meningitis. This organism is able to attach to the respiratory mucosa because it has teichoic acids in its envelope, and because it produces an IgA protease. The IgA protease physically cleaves the immunoglobulin molecules, leaving the Fc parts to coat the bacterium. This allows the organisms to bind to the Fc receptors on various mucosal cells. Streptococcus pneumoniae does not produce a C carbohydrate (choice A), and thus cannot be grouped by the Lancefield terminology. Although the organism does produce the pneumolysin, which is an alpha-hemolytic exotoxin (choice B), this toxin mediates damage to the respiratory epithelium and inhibition of leukocytic responses, not attachment to the mucosa. Streptococcus pneumoniae does not produce an hyaluronic acid capsule (choice C); Streptococcus pyogenes does. Most capsules serve to inhibit phagocytosis, rather than to mediate adhesion. Only the group A Streptococci possess an M protein (choice E), which is used to "type" them and helps inhibit phagocytosis. In a closed system, spores are formed during which of the following phases of bacterial growth? A. Decline phase B. Exponential phase C. Lag phase D. Log phase E. Stationary phase Explanation: The correct answer is E. Spore formation usually occurs during the stationary phase, when cell growth ceases because of a developing lack of nutrients or accumulation of toxins. During the phase of decline (choice A), the lack of nutrients and the accumulation of toxin become so severe that any viable organisms usually die before they can form spores. The exponential phase (choices B) and log phase (choice D) are descriptors for the steady state of active growth occurring after the lag phase and before the stationary phase. Many antibiotics are most effective in this period. The lag phase (choice C) is the initial period of adaptation, prior to growth, which occurs when organisms are introduced to a new environment. A 33-year-old HIV-positive male complains of headache and blurred vision. Physical exam reveals

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papilledema and ataxia. Head CT is normal but CSF obtained by lumbar puncture reveals encapsulated organisms observable with India ink. What is the treatment of choice for this infection? A. Amphotericin B B. Isoniazid C. Ketoconazole D. Metronidazole E. Nystatin Explanation: The correct answer is A. Amphotericin B is the most appropriate drug listed for the treatment of cryptococcal meningitis. It is a polyene antibiotic that binds to ergosterol in the fungal cell membrane, creating an artificial pore. Flucytosine is often prescribed as an adjunct medication. Fluconazole is used long-term to prevent recurrence in AIDS patients. Isoniazid (choice B) inhibits the biosynthesis of mycolic acids in the mycobacterial cell wall. It is the primary drug used against tuberculosis. It is used alone for TB prophylaxis and is used in combination with other antituberculars to treat patients with active disease. Ketoconazole (choice C) is an orally administered imidazole antifungal medication. It inhibits 14-alpha-demethylase to block the synthesis of fungal cell membrane ergosterol. Note the difference in mechanism between the polyenes, which alter ergosterol structure, and the imidazoles, which block ergosterol synthesis. Ketoconazole is often used to treat coccidioidomycosis (prevalent in California), histoplasmosis (prevalent in the Midwest), blastomycosis (prevalent in the Eastern US), paracoccidioidomycosis (prevalent in Latin America), and mucocutaneous candidiasis. Metronidazole (choice D) is an antiprotozoal drug useful in treating a variety of parasitic infections. It is the drug of choice for trichomoniasis and giardiasis and provides general anaerobic coverage. This makes it useful for treating postsurgical abdominal and pelvic Bacteroides fragilis infections or flare-ups of intestinal diverticulitis. Nystatin (choice E) is an antifungal polyene that's usually used topically but can be taken orally for oral and esophageal candidiasis. Candidal infections of the skin, mucous membranes, and vagina usually respond well to this drug. It may also be used to prevent intestinal fungal overgrowth in patients on chemotherapy. A 37-year-old man is admitted to the hospital with shortness of breath, cyanosis, and fever. Chest x-ray films reveal consolidation of the right lower lobe with relative sparing of the remaining lobes. A clinical diagnosis of lobar pneumonia is made and supported by the results of sputum cultures.

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Which of the following is the genus of the bacterium most likely to be isolated from this patient's sputum? A. Haemophilus B. Klebsiella C. Streptococcus, alpha-hemolytic D. Streptococcus, beta-hemolytic E. Streptococcus, gamma-hemolytic Explanation: The correct answer is C. The clinical and radiologic characteristics of this patient's condition are consistent with lobar pneumonia, a respiratory infection that, in its classic presentation, involves a single pulmonary lobe. In 90% to 95% of cases, the etiologic agent is Streptococcus pneumoniae (AKA pneumococcus), an alpha-hemolytic streptococcus present in the throat of 40% to 70% of healthy individuals. A small minority of cases of lobar pneumonia are due to Klebsiella pneumoniae, staphylococci, streptococci other than pneumococcus, Haemophilus influenzae, Pseudomonas, and Proteus. Penicillin is the drug of choice for pneumococcal pneumonia, but sputum cultures are necessary to identify the infectious agent and determine its antibiotic sensitivity. S. pneumoniae is a major cause of purulent meningitis in the elderly. Other alpha-hemolytic streptococci (viridans streptococci) cause subacute endocarditis in patients with previously altered cardiac valves. Streptococcus mutans and other oral streptococci have been associated with dental caries. Bacteria belonging to the genera Haemophilus(choice A) and Klebsiella (choice B) cause respiratory infections; however, in immunocompetent individuals, these bacterial infections usually result in bronchopneumonia, which leads to multilobar, and often bilateral, pulmonary involvement. Beta-hemolytic streptococci (choice D) cause countless infections in humans. Recall that classification of -hemolytic streptococci is based on their surface antigens known as Lancefield antigens. Human diseases caused by this group of bacteria include: - Streptococcus pyogenes (group A): pharyngitis, scarlet fever, erysipelas, impetigo, rheumatic fever, and glomerulonephritis - Streptococcus agalactiae (group B): neonatal sepsis and urinary infections - Enterococcus faecalis (group D): endocarditis and urinary infections Gamma-hemolytic streptococci (choice E) are streptococci that do not produce hemolysins (nonhemolytic streptococci) and are not a significant cause of human disease.

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A 67-year-old man with moderate renal dysfunction presents with influenza-like symptoms. The patient also has a red macular rash that first appeared on the ankles, then spread centrally. He reports nausea, vomiting, and profound restlessness. He states that he was recently hiking with some friends in the mountains, about a week ago. Rickettsia rickettsiae is demonstrated by immunohistochemistry on skin biopsy. Which of the following agents would be most appropriate to treat this patient's infection? A. Demeclocycline B. Doxycycline C. Methacycline D. Oxytetracycline E. Tetracycline Explanation: The correct answer is B. This patient has Rocky Mountain spotted fever. This diagnosis can be confirmed with the immunohistologic demonstration of R. rickettsiae in the skin biopsy. The tetracyclines are a class of antibiotics commonly used in the treatment of rickettsial infections, acne, and various sexually transmitted diseases, as well as in the treatment of infections caused by susceptible organisms in penicillin-allergic patients. The key to this question is knowing which tetracycline antibiotic is safest to administer to a patient with renal dysfunction. Doxycycline is secreted in an inactive form into the intestinal lumen and eliminated in the feces; therefore, its half-life is largely independent of renal or hepatic function. The other tetracyclines listed are concentrated by the liver in the bile and excreted in the urine and feces unchanged. Therefore, dosage adjustments need to be made in patients with renal impairment because of accumulation of the drug in the body. In other words, demeclocycline (choice A), methacycline (choice C), oxytetracycline (choice D), and tetracycline (choice E) will accumulate in patients with renal impairment. A 33-year-old HIV-positive male complains of headache and blurred vision. Physical exam reveals papilledema and ataxia. Head CT is normal but CSF obtained by lumbar puncture reveals encapsulated organisms observable with India ink. Which of the following is true concerning this organism? A. It can also be identified with methenamine silver stain B. It consists of branching septate hyphae C. It exists as a mycelial form at room temperature and as yeast at 37 C D. It is an encapsulated nondimorphic yeast found worldwide

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E. It is a nonencapsulated dimorphic yeast that reproduces by budding Explanation: The correct answer is D. This patient has cryptococcal meningitis, as evidenced by the "encapsulated organisms observable with India ink" in the CSF (a classic clue). Cryptococcus is a nondimorphic yeast, meaning that it exists only in the yeast form. It is encapsulated (that's why the India ink stain works so well) and it reproduces by budding. It is found worldwide in bird droppings (think pigeons). It can also cause transient pulmonary illness in otherwise healthy individuals. The methenamine silver stain (choice A) is used primarily to demonstrate Pneumocystis carinii in tissues. Branching septate hyphae (choice B) are characteristic of Aspergillus fumigatus, among other fungi. Mycoses that exist in mycelial and yeast forms (dimorphism; diphasic; choice C) are Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatidis, and Sporothrix schenckii. C. neoformans is not dimorphic and it has a capsule (choice E). A 5-year-old child who has not had routine pediatric care develops a febrile disease with cough and a blotchy rash, and is brought to the emergency room. On physical examination, there is cervical and axillary lymphadenopathy. Also noted is an erythematous, maculopapular rash behind the ears and along the hairline, involving the neck and, to a lesser extent, the trunk. Examination of this patient's oropharynx would likely reveal which of the following lesions? A. Adherent thin, whitish patch on gingiva B. Cold sores on the lips C. Curdy white material overlying an erythematous base on the oral mucosa D. Large shallow ulcers on the oral mucosa E. Multiple small white spots on the buccal mucosa Explanation: The correct answer is E. The disease described is measles (rubeola), which has the typical presentation described in the question stem. Measles is caused by a Morbillivirus, an RNA virus belonging to the Paramyxovirus family. Koplik's spots, which are pathognomonic for measles, are small, bluish-white spots on the buccal mucosa in the early stages of measles. These lesions appear just before the onset of the characteristic rash (which can also involve the extremities) and fade as the rash develops. Leukoplakia is a premalignant condition characterized by adherent whitish patches on the

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gingiva (choice A) and other sites in the oral cavity. Cold sores of the lips (choice B) are due to infection with herpes viruses. Candida infection (thrush) produces curdy white material loosely attached to an erythematous base (choice C). Aphthous ulcers are large shallow ulcers of the oral mucosa (choice D), commonly known as canker sores. Which of the following is associated with Babesiosis rather than with Ehrlichiosis or Lyme disease? A. A characteristic rash B. Arthritis of the knee C. Hemolytic anemia D. Macrophages containing intracellular organisms E. Transmission by ixodid ticks Explanation: The correct answer is C. Babesiosis is a syndrome characterized by malaise, fatigue, chills, fever, myalgia, and arthralgia lasting for weeks. The protozoans Babesia microti and Babesia divergens cause most human babesiosis. The organisms parasitize red blood cells, and have been transmitted by blood transfusions. Hemolytic anemia and hepatosplenomegaly are features of infection with these organisms; asplenic persons may have a life-threatening infection. In Lyme disease, a characteristic rash (choice A), known as erythema chronicum migrans, forms at the tick-bite site. In ehrlichiosis and babesiosis, low platelet counts may produce nonspecific purpuric lesions, but there is not characteristic rash. Arthritis of the knee (choice B) is a classic sign in untreated Lyme disease caused by Borrelia burgdorferi. Macrophages containing intracellular organisms (choice D) is the classic finding in multiple tissues infected with Ehrlichia chaffeensis. Ixodid ticks or hard-bodied ticks (choice E) are vectors for Babesiosis, Lyme disease, and human granulocytic ehrlichiosis. A United Nations representative from a poor African country has an influenza-like illness that resolves in a few days. Less than a week later, however, he develops muscle pain, spasms, and sensory disturbances. Two days after this, flaccid paralysis occurs. Which of the following is most likely to be immediately life-threatening in this patient? A. Acute renal failure B. Bowel paralysis

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C. Fulminant liver failure D. Gastrointestinal bleeding E. Respiratory paralysis Explanation: The correct answer is E. The disease is poliomyelitis. Most infections with poliovirus cause only the influenza-like symptoms, but a small percentage progress to paralytic poliomyelitis. The most common causes of death are aspiration and airway obstruction as a result of bulbar paralysis and paralysis of respiratory muscles. Arrhythmias can also be life-threatening. Acute renal failure (choice A) is usually not seen in poliomyelitis, although the bladder may become paralyzed. Bowel paralysis (choice B) can be seen, but is not usually life-threatening. Fulminant liver failure (choice C) is not a feature of poliomyelitis. Gastrointestinal bleeding (choice D) can be seen in poliomyelitis, but is not usually lifethreatening. Evaluation of an adult third world immigrant to this country demonstrates chronic headaches accompanied by chronic mild nuchal rigidity. Cerebrospinal fluid sampling demonstrates a chronic inflammatory infiltrate with lymphocytes, plasma cells, macrophages, and fibroblasts. Which of the following is the most likely etiologic agent? A. Herpes virus B. Mumps virus C. Mycobacterium tuberculosis D. Neisseria menigitidis E. Streptococcus pneumoniae Explanation: The correct answer is C. Nuchal rigidity suggests meningitis. It is convenient to classify meningitis based on the cerebrospinal fluid (CSF) findings: 1) acute pyogenic meningitis if neutrophils are markedly increased; 2) acute lymphocytic meningitis if lymphocytes (alone) are markedly increased, and 3) chronic meningitis if lymphocytes, plasma cells, macrophages, and fibroblasts are increased. This patient has chronic meningitis. The classical cause of chronic meningitis is tuberculosis, whose etiologic agent is Mycobacterium tuberculosis. Other causes include other indolent meningeal infections such as syphilis, brucellosis, and chronic fungal infections. The granulomas that are characteristic findings in other tissues may or may not be present in the meningeal tissue, and are usually not recognizable in CSF. Tubercular meningitis is now uncommon in this country. In immigrants

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from third world countries, a history of pulmonary tuberculosis may be distant, undiagnosed, or deliberately concealed. Herpes virus (choice A) and mumps virus (choice B) are causes of acute lymphocytic meningitis. Neisseria menigitidis(choice D) and Streptococcus pneumoniae(choice E) are causes of acute pyogenic meningitis. A 14-year-old girl with cystic fibrosis is admitted to the hospital with fever and shortness of breath, and is diagnosed with pneumonia. During a respiratory therapy session, she coughs up mucus that is distinctly greenish in color. Which of the following organisms should be suspected? A. Klebsiella pneumoniae B. Mycoplasma pneumoniae C. Pneumocystic carinii D. Pseudomonas aeruginosa E. Streptococcus pneumoniae Explanation: The correct answer is D. The clues suggesting infection with Pseudomonas aeruginosa are the green-tinged sputum (due to the formation of blue and green pigments by P. aeruginosa), and the association with cystic fibrosis. Unfortunately, P. aeruginosa is very difficult to treat with most antibiotics, and presents a very difficult therapeutic challenge in the management of cystic fibrosis patients. Klebsiella pneumoniae(choice A) is most often seen in alcoholics, the elderly, and diabetics. Mycoplasma pneumoniae(choice B) is a common cause of community-acquired atypical pneumonia, and is characterized by a dry, non-productive cough. Pneumocystic carinii(choice C) usually causes pneumonia in immunocompromised patients, e.g., AIDS patients. Streptococcus pneumoniae(choice E) is an important cause of typical community-acquired lobar pneumonia. A truck driver was involved in a serious accident and received second- and third-degree burns over his body. He was placed in the burn unit and, on his twelfth day of his admission, developed a wound infection with a bluish-green exudate. Treatment with chloramphenicol and tetracycline was unsuccessful. A gram-negative, motile organism was isolated that was oxidase-positive, did not ferment lactose, sucrose, or glucose, but grew on MacConkey's agar and produced a fruity aroma on that medium. Which of the following organisms was most likely isolated? A. Candida albicans

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B. Clostridium perfringens C. Escherichia coli D. Klebsiella pneumoniae E. Proteus mirabilis F. Proteus vulgaris G. Pseudomonas aeruginosa H. Serratia marcescens Explanation: The correct answer is G.Pseudomonas aeruginosa is a very common opportunist in burn patients, in whom it classically causes secondary wound infections and septicemia. It may also cause cystitis in patients with urinary catheters and pneumonia in patients with cystic fibrosis. The organism is found in water and usually gains access to the body via this source, as a contaminant in the water used in respirators or in water baths, etc. used to cleanse wounds. This organism is a non-fermenter, that is, it does not metabolize sugars by classic pathways. It produces a blue-green, water-soluble pigment (pyocyanin), and has a fruity odor when growing on laboratory media. It has a propensity for developing antibiotic resistance; current therapy employs the synergistic combination of an aminoglycoside, such as amikacin, with a cell wall synthesis inhibitor (carbenicillin, ticarcillin, or piperacillin). Candida albicans(choice A) is a normal flora yeast that will appear as very large, grampositive, spherical-to-ovoid organisms with budding daughter cells in Gram-stained preparations. Candidiasis is an opportunistic infection in individuals with a compromised immune system. The fungus usually causes mucocutaneous lesions, but in severely compromised individuals like AIDS patients, systemic disease may occur. Oral candidiasis appears as creamy, white patches of exudate that can be scraped off an inflamed tongue or buccal mucosa. Clostridium perfringens(choice B) is a gram-positive, spore-forming, anaerobic rod. It is a common cause of gas gangrene when it is introduced into a wound. The organism produces a variety of toxins and enzymes that enable it to destroy muscle tissue and spread through the soft tissues of the body. Escherichia coli(choice C) is a lactose-fermenting, gram-negative rod commonly seen as normal flora of the intestine of man. It is the most common cause of urinary bladder infections, pyelonephritis, and sepsis in patients with indwelling urinary catheters. It is also the major cause of traveler's diarrhea with watery stools and is a very important pathogen in neonates, who become infected during passage through the birth canal.

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Klebsiella pneumoniae(choice D) is a gram-negative, highly encapsulated rod that is a significant pulmonary pathogen in individuals with a compromised respiratory apparatus. It is a common cause of aspiration pneumonia and pulmonary abscesses in alcoholics and patients with chronic obstructive pulmonary disease. The organism is readily grown on standard laboratory media such as blood agar or MacConkey's enteric agar. Proteus mirabilis(choice E) and P. vulgaris(choice F) are highly motile, gram-negative rods that ferment glucose, but not lactose. Other distinguishing features include "swarming" growth on solid media (due to the high degree of motility and production of urease and hydrogen sulfide). These organisms are not commonly associated with wound infections but usually cause urinary tract infections. The ability to break down urea is thought to contribute to the development of struvite kidney stones due to the elevation of urine pH by production of ammonia. Serratia marcescens(choice H) is a gram-negative organism that is found in the environment in water, soil, and, occasionally, as normal flora of humans. It is an opportunistic pathogen that causes respiratory disease in hospitalized patients. Many strains produce a pigment, but the colonies are usually red, pink, or orange. Interestingly, the pathogenic varieties are most often non-pigmented. A 3-month-old infant presents with a 3-day history of fever, cough, and poor feeding. On examination, the baby appears ill and has a temperature of 102 F and a respiratory rate of 32. A chest x-ray film shows bilateral patchy infiltrates in the lungs. Which of the following is the most likely etiologic agent? A. Coronavirus B. Influenza type A C. Parainfluenza type 1 D. Respiratory syncytial virus E. Rhinovirus Explanation: The correct answer is D. Respiratory syncytial virus is the most common cause of bronchiolitis and pneumonia in children younger than 1 year. Outbreaks occur seasonally in winter and early spring. Infection does not result in lasting immunity, and reinfection can occur. Coronavirus (choice A) causes the common cold (nasal obstruction and discharge, sneezing, no fever or mild fever, occasional sore throat, and/or cough) and acute pharyngitis (sore throat, with or without cervical adenopathy, ulceration, and conjunctivitis). Influenza type A (choice B) is the leading cause of influenza. Influenza is a systemic illness

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characterized by the sudden onset of fever, headache, myalgias, malaise, and prostration, followed by cough, nasal obstruction, and sore throat. The lower respiratory tract may also be involved. Parainfluenza viruses (choice C) are the leading cause of croup, or acute laryngotracheobronchitis, in children. This infection involves both the upper and lower respiratory tracts. Inflammation in the subglottal area leads to hoarseness, dyspnea, a barking cough, and inspiratory stridor. Rhinovirus (choice E) is the most common cause of the common cold. A 3-year-old girl with a history of hydrocephalus is brought to the neurologist by her parents with a severe headache and fever. The girl underwent a revision of a ventricular-peritoneal shunt 1 month ago, and the neurologist suspects that an infection has occurred. Which of the following organisms would most likely be isolated from the shunt tubing? A. Bacteroides fragilis B. Corynebacterium diphtheriae C. Escherichia coli D. Staphylococcus epidermidis E. Streptococcus pneumoniae Explanation: The correct answer is D. Staphylococcal meningitis is fairly rare, occurring mostly in patients with indwelling ventricular-peritoneal shunts. Staphylococcus epidermidis, which normally colonizes the skin, is the most common organism causing this disorder; Staphylococcus aureus meningitis occasionally occurs. Bacteroides fragilis(choice A) is a common cause of anaerobic infections, including sepsis and peritonitis, but it does not commonly cause meningitis. Diphtheroids (including Corynebacterium diphtheriae, choice B) are sometimes isolated from indwelling shunts, but in many cases they are simply contaminants, since some diphtheroids are normal skin flora. Escherichia coli(choice C) is isolated from 30% to 50% of neonates with bacterial meningitis, but is not typically associated with shunt infections. Streptococcus pneumoniae(choice E) is the most common cause of bacterial meningitis in people older than 30 years; it is much less common in children. A 1-year-old child develops voluminous watery diarrhea and vomiting. She is brought to the pediatrician by her parents and evaluated, then sent home with instructions for the parents to give the

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child an electrolyte replacement solution. Which of the following viruses is the most likely cause of the child's diarrhea? A. Coronavirus B. Lymphocytic choriomeningitis virus C. Norwalk agent D. Orbivirus E. Rotavirus Explanation: The correct answer is E. Rotavirus is the major cause of diarrhea in infants and children under the age of 2. The replicates in the intestinal mucosa, producing a profuse, watery, non-bloody diarrhea, often coupled with nausea and vomiting. Transmission is by the fecal-oral route. Coronaviruses (choice A) usually cause cold-like illnesses. Lymphocytic choriomeningitis virus (choice B) can cause headache, malaise, myalgia, conjunctivitis, and, occasionally, meningitis. Norwalk agent (choice C) can also cause diarrhea, but usually affects patients older than 2 years. Orbivirus (choice D) is the cause of Colorado tick fever, which is the only tick-borne viral disease in the United States. A 3-year-old child with cystic fibrosis presents with weight loss, irritability, and a chronic productive cough. On physical exam, he is febrile and lung exam reveals intercostal retractions, wheezing, rhonchi, and rales. Chest x-ray demonstrates patchy infiltrates and atelectasis and Gram's stain of the sputum reveals slightly curved, motile gram-negative rods that grow aerobically. The microorganism responsible for this child's pneumonia is also the most common cause of which of the following diseases? A. Croup B. Epiglottitis C. Meningitis D. Otitis externa E. Otitis media Explanation: The correct answer is D. Anytime you see pneumonia in a cystic fibrosis patient you should suspect Pseudomonas aeruginosa. The Gram's stain revealing aerobic, gram-negative rods confirms your suspicion in this case. Now the question is: which of the diseases listed is also caused by Pseudomonas? The answer is otitis externa. P. aeruginosa is often found in the external ear, especially if the conditions are moist ("swimmer's

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ear") and there is any sort of inflammation. External otitis is usually a benign process with the only symptoms being an itchy, painful ear. If, however, the organism penetrates the epithelium and invades the soft tissue, cartilage, and cortical bone, the process becomes malignant otitis externa, which can progress to osteomyelitis leading to cranial nerve palsies. This condition is most common in diabetics. Croup (choice A), also called laryngotracheobronchitis, is a respiratory disease of children that presents with a characteristic "barking" cough. Croup is caused by parainfluenza virus. Epiglottitis (choice B) is a potentially fatal infection in children, caused by H. influenzae, which presents with drooling, difficulty breathing, and stridor. The incidence of this disease has dropped dramatically with the introduction of the H. influenzae type b (Hib) vaccine. Meningitis (choice C) is caused by numerous different bacteria, depending on the age of the patient. The most common causes include S. pneumoniae (elderly), H. influenzae (unvaccinated children), Group B Strep and E. Coli (neonates) and N. meningitidis (1 month - adult). While P. aeruginosa can cause meningitis, it is not a common cause. The most common causes of otitis media (choice E) include S. pneumoniae and H. influenzae. Even in cases of external ear infections with P. aeruginosa, the middle ear is typically spared. A pastry chef cut his finger while slicing a cake. After a week, the site of the injury is warm, red, and swollen, and begins draining pus. While preparing some cream pies, he contaminates the custard with drainage from the lesion. The pies were eaten several days later by patrons of the restaurant. Within 4 hours they developed diarrhea and vomiting with no fever. Which of the following organisms would be most likely to cause these symptoms? A. Bacillus cereus B. Clostridium perfringens C. Escherichia coli D. Shigella sonnei E. Staphylococcus aureus Explanation: The correct answer is E. The chef had a staphylococcal abscess on his finger. S. aureus, produces enterotoxin A, which was likely present in the cream pies. When ingested, the toxin causes severe nausea and vomiting within a few hours (the average incubation time is 3-6 hours). There is little diarrhea associated with this type of food poisoning outbreak. Bacillus cereus(choice A) is a gram-positive sporeforming rod that is associated with food

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poisoning outbreaks following the ingestion of fried rice. The time of onset and symptoms would mimic staphylococcal disease; the major differentiating feature is the food involved. The organism survives the boiling of the rice because it is a spore-former. It germinates as the rice cools, grows, and elaborates an enterotoxin that is responsible for the nausea and vomiting characteristic of the disease. Clostridium perfringens(choice B) is a gram-positive spore-forming anaerobe that can cause a longer incubation (18-24 hour) food poisoning, typically with marked diarrhea. Once again, the spores allow the organism to survive the heating process used in the preparation of the food. Both Clostridium perfringens and Clostridium botulinum are associated with home-canned vegetable and sausages. The symptoms of Escherichia coli(choice C) food poisoning are usually watery diarrhea (traveler's diarrhea) with minimal nausea and vomiting, or a bloody diarrhea caused by enteroinvasive strains of the agent. Also, E. coli would be an unlikely cause of the primary infection in the chef. Shigella sonnei (choice D) causes enterocolitis characterized by fever, cramps, and diarrhea after an incubation period of one to four days. Transmission is fecal-oral, associated with poor hygiene. A wide range of foods has been implicated. After passing his physical exam, a 19-year-old army recruit gives urine and blood samples for further testing. Serum analysis yields elevated ALT, HBsAg, Anti-HBc, HBeAg, and bilirubin. All other values are normal. Which of the following is the hepatitis B status of this recruit? A. Asymptomatic carrier B. Chronic active carrier C. Fulminant hepatitis B D. Recovered from acute self-limited HBV E. Vaccinated against HBV Explanation: The correct answer is B. The presence of elevated ALT, HBsAg, anti-HBc, HBeAg, and bilirubin all point to active hepatitis B. An asymptomatic carrier (choice A) does not have elevated ALT and bilirubin. The absence of findings on physical examination rules out fulminant hepatitis B (choice C). Recovery from acute self-limited HBV (choice D) is associated with the presence of anti-HBs and the decrease in HBsAg and HBeAg. Someone who is vaccinated with HBV (choice E) has anti-HBs only in their serum.

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* Re:micro questions with explan....from step prep..

malvika - 10/15/06 18:31

#508455

Nishi, thanks a ton for posting the above-great review! Report Abuse * Re:micro questions with explan....from step prep..
nishi - 10/15/06 18:41

#508461

your welcome malvika.....will post more on diff. subject may be in a hour or so...since i cant do one by one for long time...:) Report Abuse * Re:micro questions with explan....from step prep..
surgeon1982 - 10/15/06 18:45

#508467

hey nishi are these from stepprep. as i am also a member of that so would u please tell me how did u got those questions. as i tried but i didnt find those thanks Report Abuse * Re:micro questions with explan....from step prep..
mchill - 10/15/06 18:53

#508474

thank u nishi Report Abuse * Re:micro questions with explan....from step prep..
nishi - 10/15/06 18:53

#508475

hey surgeon, these are stepprep questions....i have no idea how to get them as i didnt pay for it....i got these from a friend of mine who had already finished his step1 so he gave me whatever he had...and i dont even know what they are from...but i will be posting most of them here...whatever i have...so just cut and paste and then go back to it later as you study....i think i posted immuno the other day...these are micro..will post more subject later....thanx. GL. Report Abuse * Re:micro questions with explan....from step prep..
nishi - 10/15/06 18:59

#508482

yrw mchill Report Abuse * Re:micro questions with explan....from

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step prep..
surgeon1982 - 10/15/06 19:25

#508526

Thanks nishi. so how is ur preparation going on??????? Report Abuse * Re:micro questions with explan....from step prep..
nishi - 10/15/06 19:31

#508536

yrw surgeon, prep is going ok....actually not studying as much....whatever i can do...cant study much during weekend....so will pick up a bit tomorrow thanx. Report Abuse * Re:micro questions with explan....from step prep..
drvirgo - 10/15/06 19:32

#508538

hi nishi..thanx for posting ques with answers..are these kaplan q bank q's or nbme...can u plz put all ques from all subjects.........thanx in advance.. Report Abuse * Re:micro questions with explan....from step prep..
ubiquit - 10/15/06 21:02

#508608

nishi, I thank you VERY much.These are great q's that take you thru subjects. Guys like you are inspiring this forum Best of luck,everybody!!!!!!!!!!!!!!!! Report Abuse Page 1 of 1 [<<First] [<Prev] ... Message ... [Next >] [Last >>]

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